COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Pre-Inspection Health and Safety Assessment Facility Name: 1QU a-.r ' FA#: �� ?,0 Location: -4115 N, EI i)OL dO TY _ ,�}�('� PR#: Q�J�J7 S 3`t Business Type: /2-e tail J'Q �•� Initially Completed By: 2 Date: /O 28 Instructions: Fill out this for s best as possible before the initial inspection and complete the remaining information during or after the inspection. Subsequent Inspections: Review facility file and chemical inventory information, along with the information on this form, to become familiar with potential hazardous substances and/or conditions at the facility and any control or precautionary measures that should be taken prior to conducting the inspection activity. Update/complete form as needed. Sign and date below. Chemical Hazards Physical Hazards Carcinogens: ❑ I Oxygen Deficiency: - Corrosives: ❑ Noise: 'O_ Flammables: ❑ Excavations: Gases: ❑ Climbing: 14 Metals: ❑ Explosion: VL Oxidizers: ❑ HeavyE ui ment: ❑ PCBs: ❑ Heat or Cold Stress: ❑ Explosives: 01 Other: Biological Hazards Personal Protective Equipment ❑ Dos ❑ Hard Hat ❑ CPC-T vek ❑ Snakes ❑ SafetyVest ❑ CPC—Other: ❑ Insects ❑ Protective Boots ❑ APR Respirator ❑ Poisonous Plants ❑ Goggles/Glasses ❑ SCBA Respirator ❑ Other: ❑ Hearing Protection ❑ Other: By signing below, I am decla ng that I have reviewed the health and safety information for this facility prior to my inspection and that I have pe ormed, and will perform during the inspection, the following actions: I have reviewed this fot'm and t e facility file for information on the business type of operation, compliance history, prior releases and responsel responseand oth r health and safety related information. I have reviewed the prperties Ind hazards associated with the chemicals in the chemical inventory submitted by the facility. I have searched out and evaluaed information on the properties of the chemicals at the facility, using the internet and other resources, for chemicals I am not familiar with at this time. I have reviewed the fac'lity inforation with my supervisor if I could not determine the most appropriate health and safety precautions needed for this facil t . I have gained an awareness ofhe potential hazards at the facility and have determined the appropriate health and safety precautions needed to perform inspection. Before beginning the inspectionI will review the facility's health and safety information and rules with the owner/manager and wear theappropriate erso al protective equipment. During the inspection, I will obs rve the labeling and condition of hazardous materials containers and conveyances, the posting of placards and warning signage, and the actions of the facility employees and guests to identify any potential unsafe conditions that may aris during the ins ection. Staff S' nature Date Staff Signature Date San Joaquin Counly Enviroi mental Health Department; 1868 E. Hazelton Avenue; Stockton, CA 95205; 209.468.3420 EHD 48- 06-12-2013 Pre-Inspection Health&Safety Assessment